Diabetes Manager www.eclipsesolutions.org.uk Julian Brown
Currently the NHS is Struggling with: Lack of Integrated Care Lack of Cohesive Patient Management Plans Lack of standardised GP information available to specialists. Lack of Patients being involved in their own health decisions. Lack of ability to track the impact we are making on diabetes outcomes Lack of ability to develop definitive pathways or key local objectives. Lack of ability to communicate these with GPs.
What if? Centralised Database of all diabetes patients in your region with all their: Conditions Medications Latest Blood Results Latest Blood Sugar Readings Healthcare Team Members assigned
A Centralised Database Changes Everything. You could then run weekly algorithms against these patients to identify those with a call to action. Track the overall response to a pathway. Remotely track those patients that you are most concerned about. Perform genuinely remote clinics Intervene in admission avoidance. Keep Patients out of hospital.
This System is Already in 35 CCGs. A Centralised Database of over 500,000 diabetes patients already exists. Personalised Management Plans for All Patients. Tracking at risk patients through the use of an integrated team. Feeding back success to the team. Better integration with extended healthcare team. Questionnaires for the Patients.
Everything is tracked Runs a search each week to: Update the Diabetes Lists Update the Risk Stratification Update the Patients Summary Updates
Performance Tracking Accurate Benchmarking of how the surgery and CCG is performing on key clinical markers. NICE QOF How are we performing in terms of outcome data?
Self-Management Plans Encourage Patients. Educate Patients. Essential in achieving longterm diabetes control. Reduce complications. Reduce costs. Makes the Patients Happy
Each Patient Has their key 9 Diabetes Indicators Tracked? These are then used to enable: Performance Tracking Risk Stratification Integrated Care Self-Management Plans Patient Access
Risk Stratification: Identification of High Risk Patients Six types of High Risk Patients 1. Those that have poor endpoint data. 2. Those that have deteriorating end point data. 3. Those that fail to have screening 4. Those who are not on or not collecting appropriate medications 5. Those that have probable diabetes but are not yet diagnosed.
Surgery Portal Identifies at risk patients Updated Weekly Confidentiality Maintained Surgery Has Control
Surgeries Can Also Monitor their Secondary Care Outcome Measures
The System Allows For True Integrated Care
Integrated Care is Achieved through Proper Data Sharing Secure online access for the key Healthcare Professionals delivering diabetes care to the patient. All the essential information they need.
Remote Assessment Improves appropriateness of response to a clinical need. Improves education of the end user Reduces load on hospital system Allows Patients to be managed remotely Follow up can be achieved remotely. Formal Analysis of outcomes.
The Process
Utilising Patient Data Remote Monitoring Upload Blood Sugars centrally Enables identification at risk individuals Blood Pressures too
Create a Centralised Database of your Diabetes Workers GPs can customise the types of alert they would like to receive and in which format. Page 34 Page 35
What is the main cause of ketoacidosis?
Blood Glucose Testing analysis is vital. Are their test results ok? What is the longest gap between testing? Is the patient testing appropriately? Is their overall profile improving?
How to Access A Patient Record Each Patient has a Patient Access Card. How will Eclipse Passport benefit your CCG? nhspatient.org allows the creation of a completely functionally integrated generic team with the Patient at the centre to allow true Patient Care. There are four key information categories needed to enable an accurate clinical assessment: 1. Patient s Clinical Conditions 2. Patient s Medications and Allergies 3. Patient s Blood Results and Investigations undertaken 4. Patient s Health Plans. Step 1 Log onto www.nhspatient.org For Healthcare Professionals this requires a username, password and 2- factor authentication. (The 2-factor authentication can be through mobile phone or finger print recognition.) Step 2 Scan the Patient s card (If you do not have a barcode scanner, simply enter the 15-digit code.) By allowing fast, easy access to this information, Eclipse Passport will radically improve the safety of: Out of Hours Consults A&E Attendances Ambulance Assessments Pharmacy Medication Use Reviews Out Patient Assessments Hospital Admissions Emergencies Abroad. The outcome of the interface will: Improve the Safety of Patient Care Improve Education of Healthcare Professionals Allow Multidisciplinary Meetings Remotely Reduce Inappropriate Referrals and Increase Appropriate Referrals Reduce Emergency Admissions. 24 Step 3 There is the option of a verification question. This is at the discretion of the patient when they activate their account. Within seconds Healthcare Professionals can access information that is needed to make life-saving decisions about their patient. GP SYSTEM HOSPITAL S AMBULANC E SERVICE PHARMAC Y Through nhspatient.org all key NHS Healthcare Workers and eventually the Patients and Carers themselves can access the patient portal if they have clearance. Each time they do access it, it is recorded who accessed which record and at what time. COMMUNITY SERVICES Page 28 Page 29
3 rd /4 th Generation Cards Increased security Increased Flexibility Wireless Capability Full Interoperability
Activating the Specialist Modules Remote Specialist Analysis Centralised Data on monitoring Allows virtual tracking of patients through Bespoke Questionnaires. Electronic Patient Passport to enable improved integrated care. Patient having access to their own records. Centralised Cloud Based Notes System
The Results 9% less admissions 17% less out patient appointments 8% less A&E Admissions 10% less Emergency Admissions
The Future Better outcome for patients Better remote support of Patients. Increasing Self-management Reduced need for medications. Easy patient alerts Easy patient tracking Better outcomes for HCPs. Reduced Emergencies. Reduced Admissions Better project and formulary compliance. Better use of services. Identification of GP Surgeries needing extra resources. Better education Online referrals / specialist support.
This can become a thing of the past! Microvascular Neuropathy Retinopathy Renal Disease Diabetic ulcers Macrovascular Heart Attacks Strokes Peripheral Ischaemia Diabetic Ulcers
Commonly Asked Questions Will this increase workload for my Practice? Will this be used for Performance Monitoring? Will this increase the chance of litigation? Is this system secure for my Patients? Do I need to get Patient Consent? Where is the Data Held? How do I and how long does it take to get activated? Who will have access to my data? Surely SystmOne or EMIS can do this?
Available for A Range of Conditions Through Single Portal All with the functionality to: Risk Stratify Risk Reduce Personalised Management Plan Integrated Care Performance Tracking Patient Access